Soap note on a *Geriatric* patient (65+ years old)
soap note on a *Geriatric* patient (65+ years old) A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient's condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow upClick here to access and download the SOAP Note TemplateDownload Click here to access and download the SOAP Note Template
Submission Instructions:
- Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
- You must use the template provided.
SOAP Note Rubric
Criteria Ratings Point s
Demographics 1 to >0.8 pts Begins with patient initials, age, race, ethnicity and gender (5 demographics)
0.8 to >0.25 pts Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender)
0.25 to >0.0 pts Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender)
0 pts Missing criteria and/or submission .
1 point
Chief Complaint (Reason for seeking health care)
4 to >3.0 pts Includes a direct quote from patient about presenting problem
3 to >2.0 pts Includes a direct quote from patient and other unrelated information
2 to >0.0 pts Includes information but information is NOT a direct quote
0 pts Missing criteria and/or submission .
4 points
History of the Present Illness (HPI)
5 to >3.0 pts Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
3 to >2.0 pts Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
2 to >0.0 pts Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity)
0 pts Missing criteria and/or submission .
5 points
Allergies 2 to >1.5 pts Includes NKA (including = Drug, Environmental, Food, Herbal, and/or Latex or if allergies are present (reports for each severity of allergy AND description of allergy)
1.5 to >1.0 pts If allergies are present, students lists type Drug, environmental factor, herbal, food, latex name and includes severity of allergy OR description of allergy
1 to >0.0 pts If allergies are present, students lists only the type of allergy name
0 pts Missing criteria and/or submission .
2 points
Review of Systems (ROS)
15 to >8.0 pts Includes a minimum of 3 assessments for each body system and assesses at least 9 body systems directed to chief complaint AND uses the words “admits” and “denies”
8 to >3.0 pts Includes 3 or fewer assessments for each body system and assesses 5-8 body systems directed to chief complaint AND uses the words “admits” and “denies”
3 to >0.0 pts Includes 3 or fewer assessments for each body system and assesses less than 5 body systems directed to chief complaint OR student does not use the words “admits” and “denies”
0 pts Missing criteria and/or submission .
15 points
Vital Signs 2 to >1.5 pts Includes all 8 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
1.5 to >1.0 pts Includes 7 vital signs, (BP (with patient position), HR, RR, temperature (with Fahrenheit or Celsius and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
1 to >0.0 pts Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with F or C and route of temperature collection), weight, height, BMI (or percentiles for pediatric population) and pain.)
0 pts Missing criteria and/or submission .
2 points
Labs 2 to >1.5 pts Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed.
1.5 to >1.0 pts Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal values.
1 to >0.0 pts Includes a list of the labs reviewed at the visit but does not include the values of lab results or highlight abnormal values.
0 pts Missing criteria and/or submission .
2 points
Medications 4 to >2.0 pts Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name,
2 to >1.0 pts Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including 3 of
1 to >0.0 pts Includes a list of all of the patient reported medications (including 2 of the 4: name,
0 pts Missing criteria and/or submission .
4 points
dose, route, frequency)
the 4: name, dose, medications route, frequency)
dose, route, frequency)
Past Medical History
3 to >2.0 pts Includes (Major/Chronic, Trauma, Hospitalizations), for each medical diagnosis, year of diagnosis and whether the diagnosis is active or current
2 to >1.0 pts Includes (Major/Chronic, Trauma, Hospitalizations) , for each medical diagnosis, either year of diagnosis OR whether the diagnosis is active or current
1 to >0.0 pts Includes each medical diagnosis but does not include year of diagnosis or whether the diagnosis is active or current
0 pts Missing criteria and/or submission .
3 points
Past Surgical History
3 to >2.0 pts Includes, for each surgical procedure, the year of procedure and the indication for the procedure
2 to >1.0 pts Includes, for each surgical procedure, the year of procedure OR indication of the procedure
1 to >0.0 pts Includes, for each surgical procedure but not the year of procedure or indication of the procedure
0 pts Missing criteria and/or submission .
3 points
Family History 3 to >2.0 pts Includes an assessment of at least 4 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
2 to >1.0 pts Includes an assessment of at least 3 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
1 to >0.0 pts Includes an assessment of at least 2 family members regarding, at a minimum, genetic disorders, diabetes, heart disease and cancer.
0 pts Missing criteria and/or submission .
3 points
Social History 3 to >2.0 pts Includes all of the required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive use, and living situation.
2 to >1.0 pts Includes 10 of the 11 required following: tobacco use, drug use, alcohol use, marital status, employment status, current/previous occupation, sexual orientation, sexually active, contraceptive
1 to >0.0 pts Includes 9 or less of the required information.
0 pts Missing criteria and/or submission .
3 points
use, and living situation.
Health Maintenance / Screenings
3 to >2.0 pts Includes a detailed assessment of immunization status and other health maintenance needs such as age- appropriate screenings and preventive measures Includes an assessment of at least 5 screening tests
2 to >1.0 pts Includes a partial assessment of immunization status and health maintenance needs, missing some key components. Includes an assessment of at least 4 screening tests
1 to >0.0 pts Includes minimal assessment of immunization status and health maintenance needs, lacking detail. Includes an assessment of at least 3 screening tests
0 pts Missing criteria and/or submission .
3 points
Physical Examination
15 to >8.0 pts Includes a minimum of 4 assessments for each body system and assesses at least 5 body systems directed to chief complaint
8 to >3.0 pts Includes a minimum of 3 assessments for each body system and assesses at least 4 body systems directed to chief complaint
3 to >0.0 pts Includes a minimum of 2 assessments for each body system and assesses at least 4 body systems directed to chief complaint
0 pts Missing criteria and/or submission .
15 points
Diagnosis
5 to >3.0 pts Includes a clear outline of the accurate principal diagnosis AND lists the remaining diagnoses addressed at the visit (in descending priority)
3 to >1.0 pts Includes a clear outline of the accurate diagnoses addressed at the visit but does not list the diagnoses in descending order of priority
1 to >0.0 pts Includes 1 differential diagnosis for the principal diagnosis
0 pts Missing criteria and/or submission .
5 points
Differential Diagnosis
5 to >3.0 pts Includes at least 3 differential diagnoses for the principal diagnosis
3 to >1.0 pts Includes at least 2 differential diagnoses for the principal diagnosis
1 to >0.0 pts Includes at least 1 differential diagnoses for the principal diagnosis
0 pts Missing criteria and/or submission .
5 points
ICD 10 Coding 3 to >2.0 pts Correctly includes all ICD-10 codes relevant to the diagnoses addressed at the visit
2 to >1.0 pts Correctly includes most ICD-10 codes relevant to the diagnoses addressed at the visit
1 to >0.0 pts Includes some ICD-10 codes relevant to the diagnoses addressed at the visit
0 pts Missing criteria and/or submission .
3 points
Pharmacologi c treatment plan
5 to >3.0 pts Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes ALL of the required following: drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
3 to >1.0 pts Includes a detailed pharmacologic treatment plan for each of the diagnoses listed under “assessment”. The plan includes 4 of the required following 7: the drug name, dose, route, frequency, duration and cost as well as education related to pharmacologic agent. If the diagnosis is a chronic problem, student includes instructions on currently prescribed medications as above.
1 to >0.0 pts Includes a detailed pharmacologi c treatment plan for each of the diagnoses listed under “assessment”. The plan includes less than 4 of the information:
0 pts Missing criteria and/or submission .
5 points
Diagnostic / Lab Testing
3 to >2.0 pts Includes appropriate diagnostic/lab testing 100% of the time OR acknowledges “no diagnostic testing clinically required at this time”
2 to >1.0 pts Includes appropriate diagnostic/lab testing 50% of the time OR acknowledges “no diagnostic testing clinically required at this time”
1 to >0.0 pts Includes appropriate diagnostic testing less than 50% of the time.
0 pts Missing criteria and/or submission .
3 points
Education 3 to >2.0 pts Includes at least 3 strategies to promote and develop skills for managing their illness and at least 3 self-management methods on how to incorporate healthy behaviors into their lives.
2 to >1.0 pts Includes at least 2 strategies to promote and develop skills for managing their illness and at least 2 self- management methods on how to incorporate healthy behaviors into their lives.
1 to >0.0 pts Includes at least 1 strategies to promote and develop skills for managing their illness and at least 1 self- management methods on how to incorporate
0 pts Missing criteria and/or submission .
3 points
healthy behaviors into their lives
Anticipatory Guidance
3 to >2.0 pts Includes at least 3 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre- natal milestone anticipatory guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
2 to >1.0 pts Includes at least 2 primary prevention strategies (related to age/condition (i.e. immunizations, pediatric and pre-natal milestone anticipator guidance)) and at least 2 secondary prevention strategies (related to age/condition (i.e. screening))
1 to >0.0 pts Includes at least 1 primary prevention strategies (related to age/condition (i.e. immunizations , pediatric and pre-natal milestone anticipatory guidance)) and at least 1 secondary prevention strategies (related to age/condition (i.e. screening))
0 pts Missing criteria and/or submission .
3 points
Follow Up Plan
2 to >1.0 pts Includes recommendation for follow up, including time frame (i.e. x # of days/weeks/months )
1 to >0.0 pts Includes recommendation for follow up, but does not include time frame (i.e. x # of days/weeks/months)
0 pts Missing criteria and/or submission .
2 points
Prescription 3 to >2.0 pts Prescription includes all required components: patient information, date, drug name, dose, route, frequency, quantity to be dispensed, refills, and provider’s signature and credentials
2 to >1.0 pts Prescription includes most required components, but is missing 1- 2 elements such as quantity to be dispensed or refills
1 to >0.0 pts Prescription is missing 3 or more required components such as patient information, date, or provider’s signature
0 pts Missing criteria and/or submission .
3 points
Writing Mechanics, Citations, and APA Style
3 to >2.0 pts Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. APA
2 to >1.0 pts Moderately use the literature and other resources to inform their work. Moderately use of citations and
1 to >0.0 pts Ineffectively uses the literature and other resources to inform their work. Ineffectively
0 pts Missing criteria and/or submission .
3 points
style is correct, and writing is free of grammar and spelling errors.
extended referencing. APA style and writing mechanics need more precision and attention to detail.
use of citations and extended referencing. APA style and writing mechanics need serious attention.
Total 100
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SOAP NOTE TEMPLATE Review the Rubric for more Guidance |
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Demographics |
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Chief Complaint (Reason for seeking health care) |
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History of Present Illness (HPI) |
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Allergies |
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Review of Systems (ROS) |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx: |
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Vital Signs |
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Labs |
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Medications |
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Past Medical History |
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Past Surgical History |
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Family History |
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Social History |
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Health Maintenance/ Screenings |
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Physical Examination |
General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: |
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Diagnosis |
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Differential Diagnosis |
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ICD 10 Coding |
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Pharmacologic treatment plan |
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Diagnostic/Lab Testing |
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Education |
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Anticipatory Guidance |
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Follow up plan |
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Prescription |
See Below (scroll down) |
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References |
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Grammar |
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EA#: 101010101 STU Clinic LIC# 10000000 |
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Tel: (000) 555-1234 FAX: (000) 555-12222 |
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Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature:____________________________________________________________ |
Signature (with appropriate credentials):_____________________________________
References (must use current evidence-based guidelines used to guide the care [Mandatory])
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SOAP |
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Demographics |
(L.S.) is a 72-year-old African American black female. |
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Chief Complaint (Reason for seeking health care) |
“My knee has been hurting and bothering me more than usual, especially when I walk or try to go up the stairs in my sister’s house.” |
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History of Present Illness (HPI) |
According to the patient, he has been experiencing increased pain in his knees over the past 6 months and the right knee is more affected now. It is a slow, unclear pain, usually registering 6/10 on the scale and rising to 8/10 if I become more active. The problem is made worse by continuing to move for hours on end by walking, standing, or climbing stairs. L.S. found that resting and taking ibuprofen helps a little. No reports of locks or instability could be found. She insists that she hasn’t been hurt or had a trauma in the recent past. Because of the pain, she has difficulty gardening, something she likes to do. |
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Allergies |
L.S. reports having an allergy to ciprofloxacin, but no environmental, herbal, latex, and/or food allergies reported. |
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Review of Systems (ROS) |
General: Denies recent gain or loss in weight, chills, or nighttime sweats. Reports occasional feelings of weakness. HEENT: Denies headaches or changes in her vision. Neck: Denies stiffness or swelling. Lungs: Denies shortness of breath or cough. Cardio: Denies chest pain or palpitations. Breast: Denies masses or nipple discharge. GI: Denies nausea, vomiting, or bowel changes. M/F genital: Denies vaginal discharge, itching, or pain. GU: Denies urinary incontinence or dysuria. Neuro: Denies dizziness or tingling. Denies balance issues. Musculo: Admits bilateral knee pain, worse on right. No joint swelling in other areas. Activity: Admits decreased mobility due to knee pain; uses rail support when climbing stairs. Psychosocial: Admits that she lives alone but has daily check-ins from her daughter. Slightly withdrawn socially due to mobility issues. Derm: Denies rashes or open wounds. Nutrition: Balanced diet; denies any alterations in her cravings or appetite. Sleep/Rest: Admits difficulty falling asleep due to knee discomfort. LMP: Patient is post-menopausal. STI Hx: Non-contribu Collepals.com Plagiarism Free Papers Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS Why Hire Collepals.com writers to do your paper? Quality- We are experienced and have access to ample research materials. We write plagiarism Free Content Confidential- We never share or sell your personal information to third parties. Support-Chat with us today! We are always waiting to answer all your questions.  All Rights Reserved Terms and Conditions |